HESI RN OB V2
,1. The nurse is caring for a client who had an emergency cesarean
section, with her husband in attendance the day before. The baby’s
Apgar was 9/9. The woman and her partner had attended childbirth 4. A client is receiving an epidural infusion of a narcotic for pain relief
education classes and had anticipated having a water birth with family after a cesarean section. The nurse would report to the anesthesiologist
present. Which of the following comments by the nurse is appropriate? if which of the following were assessed?
a) “Sometimes babies just don’t deliver the way we expect them a) Respiratory rate 8 rpm.
to.” b) Complaint of thirst.
b) “With all of your preparations, it must have been disappointing c) Urinary output of 250 cc/hr.
for you to have had a cesarean.” d) Numbness of feet and ankles.
c) “I know you had to have surgery, but you are very lucky that
your baby was born healthy.” 5. A client, 2 days postoperative from a cesarean section, complains to
d) “At least your husband was able to be with you when the baby the nurse that she has yet to have a bowel movement since the surgery.
was born.” Which of the following responses by the nurse would be appropriate at
2. A nurse has brought a 2-hour-old baby to a mother from the nursery. this time?
The nurse is going to assist the mother with the first breastfeeding a) “That is very concerning. I will request that your physician
experience. Which of the following actions should the nurse perform
order an enema for you.”
first?
b) “Two days is not that bad. Some patients go four days or longer
a) Compare mother’s and baby’s identification bracelets. without a movement.”
b) Help the mother into a comfortable position. c) “You have been taking antibiotics through your intravenous.
c) Teach the mother about a proper breast latch. That is probably why you are constipated.”
d) Tickle the baby’s lips with the mother’s nipple. d) “Fluids and exercise often help to combat constipation. Take a
3. The obstetrician has ordered that a post-op cesarean section client’s stroll around the unit and drink lots of fluid.”
patient-controlled analgesia (PCA) be discontinued. Which of the
6. A post–cesarean section, breastfeeding client, whose subjective pain
following actions by the nurse is appropriate?
level is 2/5, requests her as needed (prn) narcotic analgesics every 3
a) Discard the remaining medication in the presence of another hours. She states, “I have decided to make sure that I feel as little pain
nurse. from this experience as possible.” Which of the following should the
b) Recommend waiting until her pain level is zero to discontinue nurse conclude in relation to this woman’s behavior?
the medicine.
c) Discontinue the medication only after the analgesia is a) The woman needs a stronger narcotic order.
completely absorbed. b) The woman is high risk for severe constipation.
d) Return the unused portion of medication to the narcotics c) The woman’s breast milk volume may drop while taking the
cabinet. medicine.
d) The woman’s newborn may become addicted to the
medication.
, 7. A nurse is assessing a 1-day postpartum woman who had her baby d) Irrigate incision twice daily with antibiotic solution.
by cesarean section. Which of the following should the nurse report to
11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal
the surgeon?
delivery with local anesthesia, states that she needs to urinate. Which
a) Fundus at the umbilicus. of the following actions by the nurse is appropriate at this time?
b) Nodular breasts.
a) Provide the woman with a bedpan.
c) Pulse rate 60 bpm.
b) Advise the woman that the feeling is likely related to the
d) Pad saturation every 30 minutes.
trauma of delivery.
8. The nurse is assessing the midline episiotomy on a postpartum c) Remind the woman that she still has a catheter in place from
client. Which of the following findings should the nurse expect to see? the delivery.
a) Moderate serosanguinous drainage. d) Assist the woman to the bathroom.
b) Well-approximated edges.
12. A nurse is assessing the fundus of a client during the immediate
c) Ecchymotic area distal to the episiotomy.
postpartum period. Which of the following actions indicates that the
d) An area of redness adjacent to the incision.
nurse is performing the skill correctly?
9. A client, G1P1, who had an epidural, has just delivered a daughter,
a) The nurse measures the fundal height using a paper centimeter
Apgar 9/9, over a mediolateral episiotomy. The physician used low
tape.
forceps. While recovering, the client states, “I’m a failure. I couldn’t
b) The nurse stabilizes the base of the uterus with his or her
stand the pain and couldn’t even push my baby out by myself!” Which
dependent hand.
of the following is the best response for the nurse to make?
c) The nurse palpates the fundus with the tips of his or her
a) “You’ll feel better later after you have had a chance to rest and fingers.
to eat.” d) The nurse precedes the assessment with a sterile vaginal exam.
b) “Don’t say that. There are many women who would be ecstatic
to have that baby.”
c) “I am sure that you will have another baby. I bet that it will be 13. A 1-day postpartum woman states, “I think I have a urinary tract
a natural delivery.” infection. I have to go to the bathroom all the time.” Which of the
d) “To have things work out differently than you had planned is following actions should the nurse take?
disappointing.”
a) Assure the woman that frequent urination is normal after
10. The nurse is developing a standard care plan for postpartum clients delivery.
who have had midline episiotomies. Which of the following b) Obtain an order for a urine culture.
interventions should be included in the plan? c) Assess the urine for cloudiness.
d) Ask the woman if she is prone to urinary tract infections.
a) Assist with stitch removal on third postpartum day.
b) Administer analgesics every four hours per doctor orders.
c) Teach client to contract her buttocks before sitting.
,1. The nurse is caring for a client who had an emergency cesarean
section, with her husband in attendance the day before. The baby’s
Apgar was 9/9. The woman and her partner had attended childbirth 4. A client is receiving an epidural infusion of a narcotic for pain relief
education classes and had anticipated having a water birth with family after a cesarean section. The nurse would report to the anesthesiologist
present. Which of the following comments by the nurse is appropriate? if which of the following were assessed?
a) “Sometimes babies just don’t deliver the way we expect them a) Respiratory rate 8 rpm.
to.” b) Complaint of thirst.
b) “With all of your preparations, it must have been disappointing c) Urinary output of 250 cc/hr.
for you to have had a cesarean.” d) Numbness of feet and ankles.
c) “I know you had to have surgery, but you are very lucky that
your baby was born healthy.” 5. A client, 2 days postoperative from a cesarean section, complains to
d) “At least your husband was able to be with you when the baby the nurse that she has yet to have a bowel movement since the surgery.
was born.” Which of the following responses by the nurse would be appropriate at
2. A nurse has brought a 2-hour-old baby to a mother from the nursery. this time?
The nurse is going to assist the mother with the first breastfeeding a) “That is very concerning. I will request that your physician
experience. Which of the following actions should the nurse perform
order an enema for you.”
first?
b) “Two days is not that bad. Some patients go four days or longer
a) Compare mother’s and baby’s identification bracelets. without a movement.”
b) Help the mother into a comfortable position. c) “You have been taking antibiotics through your intravenous.
c) Teach the mother about a proper breast latch. That is probably why you are constipated.”
d) Tickle the baby’s lips with the mother’s nipple. d) “Fluids and exercise often help to combat constipation. Take a
3. The obstetrician has ordered that a post-op cesarean section client’s stroll around the unit and drink lots of fluid.”
patient-controlled analgesia (PCA) be discontinued. Which of the
6. A post–cesarean section, breastfeeding client, whose subjective pain
following actions by the nurse is appropriate?
level is 2/5, requests her as needed (prn) narcotic analgesics every 3
a) Discard the remaining medication in the presence of another hours. She states, “I have decided to make sure that I feel as little pain
nurse. from this experience as possible.” Which of the following should the
b) Recommend waiting until her pain level is zero to discontinue nurse conclude in relation to this woman’s behavior?
the medicine.
c) Discontinue the medication only after the analgesia is a) The woman needs a stronger narcotic order.
completely absorbed. b) The woman is high risk for severe constipation.
d) Return the unused portion of medication to the narcotics c) The woman’s breast milk volume may drop while taking the
cabinet. medicine.
d) The woman’s newborn may become addicted to the
medication.
, 7. A nurse is assessing a 1-day postpartum woman who had her baby d) Irrigate incision twice daily with antibiotic solution.
by cesarean section. Which of the following should the nurse report to
11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal
the surgeon?
delivery with local anesthesia, states that she needs to urinate. Which
a) Fundus at the umbilicus. of the following actions by the nurse is appropriate at this time?
b) Nodular breasts.
a) Provide the woman with a bedpan.
c) Pulse rate 60 bpm.
b) Advise the woman that the feeling is likely related to the
d) Pad saturation every 30 minutes.
trauma of delivery.
8. The nurse is assessing the midline episiotomy on a postpartum c) Remind the woman that she still has a catheter in place from
client. Which of the following findings should the nurse expect to see? the delivery.
a) Moderate serosanguinous drainage. d) Assist the woman to the bathroom.
b) Well-approximated edges.
12. A nurse is assessing the fundus of a client during the immediate
c) Ecchymotic area distal to the episiotomy.
postpartum period. Which of the following actions indicates that the
d) An area of redness adjacent to the incision.
nurse is performing the skill correctly?
9. A client, G1P1, who had an epidural, has just delivered a daughter,
a) The nurse measures the fundal height using a paper centimeter
Apgar 9/9, over a mediolateral episiotomy. The physician used low
tape.
forceps. While recovering, the client states, “I’m a failure. I couldn’t
b) The nurse stabilizes the base of the uterus with his or her
stand the pain and couldn’t even push my baby out by myself!” Which
dependent hand.
of the following is the best response for the nurse to make?
c) The nurse palpates the fundus with the tips of his or her
a) “You’ll feel better later after you have had a chance to rest and fingers.
to eat.” d) The nurse precedes the assessment with a sterile vaginal exam.
b) “Don’t say that. There are many women who would be ecstatic
to have that baby.”
c) “I am sure that you will have another baby. I bet that it will be 13. A 1-day postpartum woman states, “I think I have a urinary tract
a natural delivery.” infection. I have to go to the bathroom all the time.” Which of the
d) “To have things work out differently than you had planned is following actions should the nurse take?
disappointing.”
a) Assure the woman that frequent urination is normal after
10. The nurse is developing a standard care plan for postpartum clients delivery.
who have had midline episiotomies. Which of the following b) Obtain an order for a urine culture.
interventions should be included in the plan? c) Assess the urine for cloudiness.
d) Ask the woman if she is prone to urinary tract infections.
a) Assist with stitch removal on third postpartum day.
b) Administer analgesics every four hours per doctor orders.
c) Teach client to contract her buttocks before sitting.
